|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
636T0028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna Commercial |
$0.37
|
| Rate for Payer: Anthem Medicaid |
$0.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.37
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna Commercial |
$0.40
|
| Rate for Payer: First Health Commercial |
$0.46
|
| Rate for Payer: Humana Commercial |
$0.41
|
| Rate for Payer: Humana KY Medicaid |
$0.17
|
| Rate for Payer: Kentucky WC Medicaid |
$0.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.42
|
| Rate for Payer: Ohio Health Group HMO |
$0.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.33
|
| Rate for Payer: PHCS Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Payer |
$0.42
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
OP
|
$98.79
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
25002011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.64 |
| Max. Negotiated Rate |
$94.84 |
| Rate for Payer: Aetna Commercial |
$76.07
|
| Rate for Payer: Anthem Medicaid |
$33.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.06
|
| Rate for Payer: Cash Price |
$49.40
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: First Health Commercial |
$93.85
|
| Rate for Payer: Humana Commercial |
$83.97
|
| Rate for Payer: Humana KY Medicaid |
$33.97
|
| Rate for Payer: Kentucky WC Medicaid |
$34.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.94
|
| Rate for Payer: Ohio Health Group HMO |
$74.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.17
|
| Rate for Payer: PHCS Commercial |
$94.84
|
| Rate for Payer: United Healthcare All Payer |
$86.94
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
636T0028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna Commercial |
$0.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.37
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna Commercial |
$0.40
|
| Rate for Payer: First Health Commercial |
$0.46
|
| Rate for Payer: Humana Commercial |
$0.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.42
|
| Rate for Payer: Ohio Health Group HMO |
$0.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.33
|
| Rate for Payer: PHCS Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Payer |
$0.42
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
IP
|
$98.79
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
25002011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.64 |
| Max. Negotiated Rate |
$94.84 |
| Rate for Payer: Aetna Commercial |
$76.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.06
|
| Rate for Payer: Cash Price |
$49.40
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: First Health Commercial |
$93.85
|
| Rate for Payer: Humana Commercial |
$83.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.94
|
| Rate for Payer: Ohio Health Group HMO |
$74.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$79.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.17
|
| Rate for Payer: PHCS Commercial |
$94.84
|
| Rate for Payer: United Healthcare All Payer |
$86.94
|
|
|
TESTOSTERONE (TOTAL)
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
30000522
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$156.60 |
| Rate for Payer: Aetna Commercial |
$47.61
|
| Rate for Payer: Ambetter Exchange |
$25.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$25.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$25.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.97
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$22.78
|
| Rate for Payer: Healthspan PPO |
$21.34
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$25.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.81
|
| Rate for Payer: Multiplan PHCS |
$156.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$33.55
|
| Rate for Payer: UHCCP Medicaid |
$91.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$25.81
|
|
|
TESTOSTERONE (TOTAL)
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
30000522
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$250.56 |
| Rate for Payer: Aetna Commercial |
$200.97
|
| Rate for Payer: Anthem Medicaid |
$25.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$209.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$36.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$25.81
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$216.63
|
| Rate for Payer: First Health Commercial |
$247.95
|
| Rate for Payer: Humana Commercial |
$221.85
|
| Rate for Payer: Humana KY Medicaid |
$25.81
|
| Rate for Payer: Humana Medicare Advantage |
$25.81
|
| Rate for Payer: Kentucky WC Medicaid |
$26.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$192.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$229.68
|
| Rate for Payer: Ohio Health Group HMO |
$195.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$208.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$180.09
|
| Rate for Payer: PHCS Commercial |
$250.56
|
| Rate for Payer: United Healthcare All Payer |
$229.68
|
|
|
TESTOSTERONE (TOTAL)
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
30000522
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.30 |
| Max. Negotiated Rate |
$250.56 |
| Rate for Payer: Aetna Commercial |
$200.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$209.58
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$216.63
|
| Rate for Payer: First Health Commercial |
$247.95
|
| Rate for Payer: Humana Commercial |
$221.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$192.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$229.68
|
| Rate for Payer: Ohio Health Group HMO |
$195.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$208.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$180.09
|
| Rate for Payer: PHCS Commercial |
$250.56
|
| Rate for Payer: United Healthcare All Payer |
$229.68
|
|
|
TETANUS & DIPHTHERIA +>7YRS
|
Facility
|
IP
|
$196.75
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
25000038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.02 |
| Max. Negotiated Rate |
$188.88 |
| Rate for Payer: Aetna Commercial |
$151.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$153.47
|
| Rate for Payer: Cash Price |
$98.38
|
| Rate for Payer: Cigna Commercial |
$163.30
|
| Rate for Payer: First Health Commercial |
$186.91
|
| Rate for Payer: Humana Commercial |
$167.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$161.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$145.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$173.14
|
| Rate for Payer: Ohio Health Group HMO |
$147.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$171.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$135.76
|
| Rate for Payer: PHCS Commercial |
$188.88
|
| Rate for Payer: United Healthcare All Payer |
$173.14
|
|
|
TETANUS & DIPHTHERIA +>7YRS
|
Facility
|
OP
|
$196.75
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
25000038
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.02 |
| Max. Negotiated Rate |
$188.88 |
| Rate for Payer: Aetna Commercial |
$151.50
|
| Rate for Payer: Anthem Medicaid |
$67.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$153.47
|
| Rate for Payer: Cash Price |
$98.38
|
| Rate for Payer: Cigna Commercial |
$163.30
|
| Rate for Payer: First Health Commercial |
$186.91
|
| Rate for Payer: Humana Commercial |
$167.24
|
| Rate for Payer: Humana KY Medicaid |
$67.66
|
| Rate for Payer: Kentucky WC Medicaid |
$68.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$161.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$145.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$69.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$173.14
|
| Rate for Payer: Ohio Health Group HMO |
$147.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$171.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$135.76
|
| Rate for Payer: PHCS Commercial |
$188.88
|
| Rate for Payer: United Healthcare All Payer |
$173.14
|
|
|
TETANUS+DIPH TOX,ADLT 0.5mL VL
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
25004096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.00 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.20
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$157.70
|
| Rate for Payer: First Health Commercial |
$180.50
|
| Rate for Payer: Humana Commercial |
$161.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.20
|
| Rate for Payer: Ohio Health Group HMO |
$142.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$165.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.10
|
| Rate for Payer: PHCS Commercial |
$182.40
|
| Rate for Payer: United Healthcare All Payer |
$167.20
|
|
|
TETANUS+DIPH TOX,ADLT 0.5mL VL
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
25004096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.00 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Anthem Medicaid |
$65.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.20
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$157.70
|
| Rate for Payer: First Health Commercial |
$180.50
|
| Rate for Payer: Humana Commercial |
$161.50
|
| Rate for Payer: Humana KY Medicaid |
$65.34
|
| Rate for Payer: Kentucky WC Medicaid |
$66.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.20
|
| Rate for Payer: Ohio Health Group HMO |
$142.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$165.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.10
|
| Rate for Payer: PHCS Commercial |
$182.40
|
| Rate for Payer: United Healthcare All Payer |
$167.20
|
|
|
TETRABENAZINE 12.5mg TABLET
|
Facility
|
OP
|
$9.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004289
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: Aetna Commercial |
$7.19
|
| Rate for Payer: Anthem Medicaid |
$3.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.29
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna Commercial |
$7.75
|
| Rate for Payer: First Health Commercial |
$8.87
|
| Rate for Payer: Humana Commercial |
$7.94
|
| Rate for Payer: Humana KY Medicaid |
$3.21
|
| Rate for Payer: Kentucky WC Medicaid |
$3.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.22
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.44
|
| Rate for Payer: PHCS Commercial |
$8.97
|
| Rate for Payer: United Healthcare All Payer |
$8.22
|
|
|
TETRABENAZINE 12.5mg TABLET
|
Facility
|
IP
|
$9.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004289
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$8.97 |
| Rate for Payer: Aetna Commercial |
$7.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.29
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Cigna Commercial |
$7.75
|
| Rate for Payer: First Health Commercial |
$8.87
|
| Rate for Payer: Humana Commercial |
$7.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.22
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.44
|
| Rate for Payer: PHCS Commercial |
$8.97
|
| Rate for Payer: United Healthcare All Payer |
$8.22
|
|
|
TETRABENAZINE 25mg TABLET
|
Facility
|
IP
|
$10.68
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.25 |
| Rate for Payer: Aetna Commercial |
$8.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.33
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna Commercial |
$8.86
|
| Rate for Payer: First Health Commercial |
$10.15
|
| Rate for Payer: Humana Commercial |
$9.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.40
|
| Rate for Payer: Ohio Health Group HMO |
$8.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.37
|
| Rate for Payer: PHCS Commercial |
$10.25
|
| Rate for Payer: United Healthcare All Payer |
$9.40
|
|
|
TETRABENAZINE 25mg TABLET
|
Facility
|
OP
|
$10.68
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.25 |
| Rate for Payer: Aetna Commercial |
$8.22
|
| Rate for Payer: Anthem Medicaid |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.33
|
| Rate for Payer: Cash Price |
$5.34
|
| Rate for Payer: Cigna Commercial |
$8.86
|
| Rate for Payer: First Health Commercial |
$10.15
|
| Rate for Payer: Humana Commercial |
$9.08
|
| Rate for Payer: Humana KY Medicaid |
$3.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.40
|
| Rate for Payer: Ohio Health Group HMO |
$8.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.37
|
| Rate for Payer: PHCS Commercial |
$10.25
|
| Rate for Payer: United Healthcare All Payer |
$9.40
|
|
|
TETRACAINE 0.5% 5mL EYE DROPS
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004444
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem Medicaid |
$62.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Humana KY Medicaid |
$62.25
|
| Rate for Payer: Kentucky WC Medicaid |
$62.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.89
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
TETRACAINE 0.5% 5mL EYE DROPS
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004444
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.89
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
TETRACAINE OPHT SOL .5% EA GTT
|
Facility
|
OP
|
$325.00
|
|
|
Service Code
|
NDC 68682092064
|
| Hospital Charge Code |
25003519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$250.25
|
| Rate for Payer: Anthem Medicaid |
$111.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$269.75
|
| Rate for Payer: First Health Commercial |
$308.75
|
| Rate for Payer: Humana Commercial |
$276.25
|
| Rate for Payer: Humana KY Medicaid |
$111.77
|
| Rate for Payer: Kentucky WC Medicaid |
$112.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.00
|
| Rate for Payer: Ohio Health Group HMO |
$243.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.25
|
| Rate for Payer: PHCS Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Payer |
$286.00
|
|
|
TETRACAINE OPHT SOL .5% EA GTT
|
Facility
|
IP
|
$325.00
|
|
|
Service Code
|
NDC 68682092064
|
| Hospital Charge Code |
25003519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$250.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$253.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$269.75
|
| Rate for Payer: First Health Commercial |
$308.75
|
| Rate for Payer: Humana Commercial |
$276.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$266.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$286.00
|
| Rate for Payer: Ohio Health Group HMO |
$243.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.25
|
| Rate for Payer: PHCS Commercial |
$312.00
|
| Rate for Payer: United Healthcare All Payer |
$286.00
|
|
|
TETRACAINE/PF 0.5% PER DROP
|
Facility
|
IP
|
$88.88
|
|
|
Service Code
|
NDC 65074114
|
| Hospital Charge Code |
25003518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.66 |
| Max. Negotiated Rate |
$85.32 |
| Rate for Payer: Aetna Commercial |
$68.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$69.33
|
| Rate for Payer: Cash Price |
$44.44
|
| Rate for Payer: Cigna Commercial |
$73.77
|
| Rate for Payer: First Health Commercial |
$84.44
|
| Rate for Payer: Humana Commercial |
$75.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$78.21
|
| Rate for Payer: Ohio Health Group HMO |
$66.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$77.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.33
|
| Rate for Payer: PHCS Commercial |
$85.32
|
| Rate for Payer: United Healthcare All Payer |
$78.21
|
|
|
TETRACAINE/PF 0.5% PER DROP
|
Facility
|
OP
|
$88.88
|
|
|
Service Code
|
NDC 65074114
|
| Hospital Charge Code |
25003518
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.66 |
| Max. Negotiated Rate |
$85.32 |
| Rate for Payer: Aetna Commercial |
$68.44
|
| Rate for Payer: Anthem Medicaid |
$30.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$69.33
|
| Rate for Payer: Cash Price |
$44.44
|
| Rate for Payer: Cigna Commercial |
$73.77
|
| Rate for Payer: First Health Commercial |
$84.44
|
| Rate for Payer: Humana Commercial |
$75.55
|
| Rate for Payer: Humana KY Medicaid |
$30.57
|
| Rate for Payer: Kentucky WC Medicaid |
$30.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$78.21
|
| Rate for Payer: Ohio Health Group HMO |
$66.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$77.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.33
|
| Rate for Payer: PHCS Commercial |
$85.32
|
| Rate for Payer: United Healthcare All Payer |
$78.21
|
|
|
TETRACYCLINE 250 MG 250MG/1CAP
|
Facility
|
IP
|
$9.67
|
|
|
Service Code
|
NDC 51991090601
|
| Hospital Charge Code |
25001513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.67
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
TETRACYCLINE 250 MG 250MG/1CAP
|
Facility
|
OP
|
$9.67
|
|
|
Service Code
|
NDC 51991090601
|
| Hospital Charge Code |
25001513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem Medicaid |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Humana KY Medicaid |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.67
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
TETRACYCLINE 500 MG CAPSULE
|
Facility
|
OP
|
$11.29
|
|
|
Service Code
|
NDC 51991090701
|
| Hospital Charge Code |
25001514
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.39 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$8.69
|
| Rate for Payer: Anthem Medicaid |
$3.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.81
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cigna Commercial |
$9.37
|
| Rate for Payer: First Health Commercial |
$10.73
|
| Rate for Payer: Humana Commercial |
$9.60
|
| Rate for Payer: Humana KY Medicaid |
$3.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.94
|
| Rate for Payer: Ohio Health Group HMO |
$8.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.79
|
| Rate for Payer: PHCS Commercial |
$10.84
|
| Rate for Payer: United Healthcare All Payer |
$9.94
|
|
|
TETRACYCLINE 500 MG CAPSULE
|
Facility
|
IP
|
$11.29
|
|
|
Service Code
|
NDC 51991090701
|
| Hospital Charge Code |
25001514
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.39 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$8.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.81
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cigna Commercial |
$9.37
|
| Rate for Payer: First Health Commercial |
$10.73
|
| Rate for Payer: Humana Commercial |
$9.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.94
|
| Rate for Payer: Ohio Health Group HMO |
$8.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.79
|
| Rate for Payer: PHCS Commercial |
$10.84
|
| Rate for Payer: United Healthcare All Payer |
$9.94
|
|
